Modified Rankin Scale (MRS)

Purpose

The Modified Rankin Scale (MRS) is a single item, global outcomes rating scale for patients post-stroke. It is used to categorize level of functional independence with reference to pre-stroke activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
rather than on observed performance of a specific task.

In-Depth Review

Purpose of the measure)

The Modified Rankin Scale (MRS) is a single item, global outcomes rating scale for patients post-stroke. It is used to categorize level of functional independence with reference to pre-stroke activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
rather than on observed performance of a specific task.

Available versions

The original Rankin Scale was developed in Scotland in 1957 and was used to assess disability in patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (Rankin, 1957). It consisted of a single item, with five grades representing no, slight, moderate, moderately severe, and severe disability. The Rankin Scale was modified in 1988 as part of a study of aspirin in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. prevention (UK-TIA Study Group, 1988) and renamed the MRS. This modification was not reported in the aspirin study, but was described subsequently by van Swieten, Koudstaal, Visser, Schouten, and van Gijn (1988). An additional grade was included (grade 0 = no symptoms at all) because of reported concerns about a lack of grading comprehensiveness. The wording of the definitions for grades 1 and 2 were also altered because of concerns of ambiguity (Bamford, Sandercock, Warlow, & Slattery, 1989). The changes were reportedly also made to accommodate language disorders and cognitive defects, to allow comparison between patients with different kinds of neurological deficits and to add a further dimension by referring to previous activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
(van Swieten et al., 1988).

Features of the measure

Items:

The MRS is a single item scale.

The conventional method of administration for the MRS is a guided interview process. The assessment is carried out by asking the patient about their activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living, including outdoor activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
. Information about the patient’s neurological deficits on examination, including aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person's ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person's intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) and intellectual deficits, should be obtained. All aspects of the patient’s physical, mental performance, and speech should be combined in the choice of a single MRS grade.

The categories within the MRS have been criticized as being broad and poorly defined, left open to the interpretation of the individual rater (Wilson et al., 2002). A structured interview format for the administration of the MRS is available (see section Alternative forms of the Modified Rankin Scale – MRS).

Scoring:

A single MRS grade should be assigned based on the following criteria (Dromerick, Edwards, & Diringer, 2003):

Rankin Grade	Description
0	No symptoms
1	No significant disability despite symptoms; able to carry out all usual duties and activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
2	Slight disability: unable to carry out all previous activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. but able to look after own affairs without assistance
3	Moderate disability: requiring some help, but *able to walk without assistance
4	Moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance
5	Severe disability: bedridden, incontinent, and requiring constant nursing care and attention

* It is unclear whether the term ‘without assistance’ allows for aids or modifications, or whether it refers only to assistance from another person.

Some studies have examined the ability of MRS scores to be dichotomized. de Haan, Limburg, Bossuyt, van der Meulen, and Aaronson (1995) suggested that MRS scores be dichotomized for the purposes of comparison in evaluating the effectiveness of an intervention. They suggested that a score of 0-3 indicate mild to moderate disability, and a score of 4-5 indicate severe disability. Currently, there is no standardized or consistent method of dichotomization (Sulter, Steen, & de Keyser, 1999), as there is a lack of consensus regarding favorable vs. unfavorable poor outcome in terms of Rankin score. Dichotomization has also been criticized as being associated with a loss of information when determining the benefits derived from a particular rehabilitation intervention. For example, Lai and Duncan (2001) reported that 62% of patients included in their study experienced recovery represented by a shift of 1 or more Rankin grades in the first 3 months following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. If these shifts were between grades 0 and 1 or between 4 and 5, for example, no change would be reported using a dichotomized system of outcomes where favourable outcome was defined as MRS = 0, 1, and 2 and unfavourable as MRS = 3, 4 or 5. In a study from Weisscher, Vermeulen, Roos, and de Haan (2008), 15% of patients were classified as having a favorable outcome when it was defined as MRS = 0-1. Among these patients, 84% were able to perform outdoor activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
. When favorable outcome was defined as a MRS = 0-2, 37% were classified as having a favorable outcome. However, among this group, only 56% were able to perform outdoor activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
. Lai and Duncan (2001) have suggested that transition in Rankin grades may be more appropriate in the assessment of intervention benefit. Weisscher et al. (2008) stated that defining favorable and unfavorable outcomes is an arbitrary decision.

The authors suggested that if favorable outcome is expressed by the ability to perform outdoor activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
then the score 0-1 should be chosen. However, if complex ADL are considered as the main outcome, then a score of 0-2 on the MRS should be considered the best dichotomization option. Sulter et al. (1999) suggest that an appropriate definition may be that poor outcome exists if any of the following occur: death, institutionalization due to strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., MRS score >3, or Barthel Index score <60.

Time:

5-15 minutes (New & Bushbinder, 2006)

Subscales:

There are no subscales to the MRS.

Equipment:

Administration of the MRS does not require any specialized equipment.

Training:

No formal training is required to administer the MRS.

Alternative form of the Modified Rankin Scale (MRS)

• Modified Rankin Scale-Structured Interview (MRS-SI) (Wilson et al., 2002).
• Wilson et al. (2002) developed a structured interview to improve the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
  of the MRS. The structured interview differs from the conventional guided interview for the MRS by defining specific questions to grade each category. The structured interview developed for the study consisted of 5 sections: (1) constant care (e.g. does the person require constant care?), (2) basic ADL (e.g. is assistance essential for eating, using the toilet, daily hygiene, or walking?), (3) instrumental ADL (e.g. is assistance essential for preparing a simple meal, doing household chores, looking after money, shopping, or traveling locally?), (4) limitations in participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. in usual social roles (e.g. has there been a change in the person’s ability to participate in previous social and leisure activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
  ?), and (5) checklist for the presence of common strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. symptoms (e.g. does the person have difficulty reading/writing, speaking or finding the right word, problems with balance/coordination, visual problems, numbness, difficulty with swallowing, or other symptom resulting from strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.?). Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
  improved significantly after training in the structured interview (Wilson et al., 2005). Furthermore, the extent of disagreement between raters on the MRS-SI was less than what has been observed with the MRS.

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Should not be used with:

• The MRS has not been evaluated for use with proxy respondents.

In what languages is the measure available?

The MRS is available in:

• German (Berger et al., 1999)
• Persian (Oveisgharan et al., 2006)
• Dutch (e.g. Hop, Rinkel, Algra, & van Gijn, 1998).

Summary

What does the tool measure?	Level of post-stroke functional independence.
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
Time to administer	The MRS takes 5-15 minutes to administer.
Versions	Original Rankin Scale (RS), Modified Rankin Scale-Structured Interview (MRS-SI)
Other Languages	German, Persian, Dutch
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the MRS. Test-rest: Two studies have examined the test-rest reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . of the MRS and reported excellent test-retest. Intra-rater: Only one study has examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the MRS and reported excellent intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. . Inter-rater: Six studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the MRS. Two reported adequate to excellent, three reported excellent inter-rater (note: one study used an expanded guidance scheme – guided interview format -, two reported systematic differences between raters using ANOVA), and one reported poor inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. .
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: Excellent correlations with the Barthel Index, Frenchay ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. Index, the motor component of the Functional Independence Measure, Short Form-36 Physical Functioning subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). and the Euroqol 5D.Adequate correlations with the Stroke-Adapted Sickness Impact Profile-30 and the Glasgow Coma Scale as well as adequate to excellent correlations with Magnetic Resonance Imaging (MRI) findings. Predictive: The most relevant predictors were MRS scores before the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. event, the presence of diabetes, and severity of left arm weakness. Construct: Convergent/Discriminant: One study reported that the MRS was closely related to the Glasgow Outcome Scale, the NIH StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale, and the Barthel Index. One study reported an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the MRS and the Barthel Index. One study reported adequate to excellent correlations between the MRS and five impairment scales (the Orgogozo Scale, the NIH StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Scale, the Canadian Neurological Scale, the Mathew scale, and the Scandinavian StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Scale). Finally, one study reported a weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the MRS and the Sickness Impact Profile subscales of Cognitive Alertness and Social Interaction.
Floor/Ceiling Effects	One study examined the floor effects of the MRS and reported an adequate floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also “ceiling effect.” .
Does the tool detect change in patients?	One study examined the responsivenessThe ability of an instrument to detect clinically important change over time. of the MRS when administered to strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation inpatients at admission and discharge and reported that the MRS was poor at detecting change.
Acceptability	The MRS has not been evaluated for use with proxy respondents.
Feasibility	The MRS is single item, global outcomes rating scale that takes 5 -15 minutes to administer and does not require any formal training or specialized equipment. The categories of the MRS have been criticized for being broad, poorly defined and left open to rater interpretation. The MRS- Structured Interview (MRS-SI) differs from the conventional guided interview format of the MRS by defining specific questions to grade each category. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the MRS has been shown to improve with the use of this structured interview format.
How to obtain the tool?	Please click here to obtain a copy of the MRS.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the MRS.

Floor/Ceiling Effects

Dromerick, Edwards, and Diringer (2003) administered the MRS to 95 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation inpatients and reported that the MRS displayed an adequate floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
(18%) at admission to rehabilitation.

Reliability

Test-retest:
Wolfe, Taub, Woodrow, and Burney (1991) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the MRS in 50 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. of varying severity. Two out of three research nurses interviewed patients on two occasions that were 2-3 weeks apart. The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
using the weighted kappa statisticA measure of the degree of nonrandom agreement between observers or measurements of the same categorical variable (Last JM, A Dictionary of Epidemiology, 2nd Ed, Oxford University Press, 1988).
was excellent (kappa w = .95).

Wilson et al. (2005) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the MRS in patients at least 6 months post-stroke, using two raters who performed repeat assessments with a mean test-retest interval of 7 days. Agreement was measured using the kappa statisticA measure of the degree of nonrandom agreement between observers or measurements of the same categorical variable (Last JM, A Dictionary of Epidemiology, 2nd Ed, Oxford University Press, 1988).
. Comparison of Rankin grades showed that there was excellent agreement between the first and second assessments. Agreement between the first and second assessments was found in 85% of cases for rater 1 (kappa = 0.81; kappa w = 0.94), and in 96% for rater 2 (kappa = 0.95; kappa w = 0.99).

Intra-rater:
Wolfe et al. (1991) examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the MRS in a sample of 14 patients who were assessed twice by the same observer within a 2-week period at least 3 months post-stroke. Exact agreement was reported in 86% of observations (kappa w = 0.95). The intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the MRS as reported in this study is considered to be excellent.

Inter-rater:
van Swieten et al. (1988) examined the inter-rater reliablity of the MRS in 100 patients who were interviewed by two physicians using kappa statistics. Physician agreement on the degree of handicap of the patients occurred for 65% of the patients. The physicians differed by one Rankin grade in 32% of the patients and by two grades in 3% of the patients. The kappa for all pairwise observations was adequate (kappa = 0.56; kappa w = 0.91). For the outpatient group, the kappa was excellent (kappa = 0.82). For the inpatient group, the kappa was adequate (kappa = 0.51).

Wolfe et al (1991) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MRS in 50 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. of varying severity. Two out of three research nurses interviewed patients. The kappa coefficients were excellent and ranged from kappa = 0.75 to kappa = 0.96. However, analysis of variance revealed that there was evidence of a systematic difference between the raters (F 2,48 = 6.02, p = 0.005), with raters 1 and 3 estimating the grade 0.42 and 0.33 points higher than rater 2.

Wilson et al. (2002) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MRS in 63 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The MRS was administered by two raters. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was measured with the kappa statisticA measure of the degree of nonrandom agreement between observers or measurements of the same categorical variable (Last JM, A Dictionary of Epidemiology, 2nd Ed, Oxford University Press, 1988).
and was found to be excellent (kappa w = 0.78). However, overall agreement between the 2 raters was only 57%, and one rater assigned significantly lower grades than the other (p = 0.048).

Wilson et al. (2005) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MRS in patients at least 6 months post-stroke. Fifteen raters were recruited for the study and pairs of raters assessed a total of 113 patients on the MRS. Agreement between raters was observed in only 43% of cases (kappa = 0.25, kappa w = 0.71).

Shinohara, Minematsu, Amano, and Ohashi (2006) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MRS when an expanded guidance scheme (a guided interview format) and corresponding questionnaire was used. Twenty raters (neurologists and nurses) watched videotapes of 30 patients interviewed and scored each patient. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was calculated using the intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance.. In this study, inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was excellent (ICC = 0.95 for neurologists and ICC = 0.96 for nurses).

Quinn, Dawson, Walters, and Lees (2008) assessed the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MRS among 2942 evaluators from 30 different countries. The evaluators rated 5 non-scripted videotaped interviews. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was calculated using Kappa statistics. The overall inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MRS was adequate (kappa = 0.67). The agreement level at each grade of the MRS was poor for a score of 0 (kappa = 0.19), adequate for a score of 2 (kappa = 0.48) and 3 (kappa = 0.74), and excellent for a score of 4 (kappa = 0.95). The agreement level for scores of 0 and 5 were not reported since the videotaped interviews did not include clients with a full range of disabilities. The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
by country was poor for Italy (kappa = 0.34), adequate for Belgium (kappa = 0.73), Czech Republic (kappa = 0.68), France (kappa = 0.64), Hungary (kappa = 0.70), Netherlands (kappa = 0.50), South Korea (kappa = 0.67), Sweden (kappa = 0.65), Unites States (kappa = 0.73) and the United Kingdom (kappa = 0.69) and excellent for Australia (kappa = 0.77), Germany (kappa = 0.78), Portugal (kappa = 0.80), Slovakia (kappa = 0.75) and Spain (kappa = 0.84). The agreement level was excellent for both native and non-native English speakers (kappa = 0.77; kappa = 0.76). Among assessors from the United Kingdom the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was adequate for all professional backgrounds: general medicine (kappa = 0.66), geriatrics (kappa = 0.54), neurology (kappa = 0.56), and research assistants (kappa = 0.65).
Note: The inter-reliability by country was calculated only for countries with more than 50 certified evaluators.

Validity

Criterion:

Concurrent:
Cup, Scholte op Reimer, Thijssen, and van Kuyk-Minis (2003) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the MRS with the Canadian Occupational Performance Measure (COPM), the Barthel Index (BI), the Frenchay ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
Index (FAI), the Stroke-Adapted Sickness Impact Profile-30 (SA-SIP30), and the Euroqol 5D (EQ-5D) in 26 patients post-stroke at their place of residence. The MRS had a statistically significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the BI, FAI, SA-SIP30 and the EQ-5D. Spearman’s rho correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients were excellent for the BI, FAI and EQ-56 (r = -0.81, -0.80, and 0.68, respectively). An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the MRS and the SA-SIP30 (r = 0.47).
Note: Some correlations are negative because a high score on the MRS indicates increased impairment whereas a low score on other measures indicates increased impairment.

Kwon, Harzema, Duncan, and Min-Lai (2004) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the Barthel Index (BI), the motor component of the Functional Independence Measure (M-FIM), and the MRS using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Excellent correlations were observed between the MRS and the BI (r = -0.89) and between the M-FIM and the MRS (r = -0.89).

Weimar et al. (2002) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the MRS from a sample of 4,264 patients with acute ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. from 30 hospitals in Germany during a 1-year period. The patients were administered the Barthel Index (BI), the MRS, the Short Form-36 Physical Functioning subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(SF-36 PF), and the Center for Epidemiologic Studies-Depression short form (CES-D). The MRS had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the SF-36 PF (r = 0.84) and with the BI (r = 0.82).

Schaefer, Huisman, Sorensen, Gonzalez, and Schwamm (2004) examined whether diffusion-weighted Magnetic Resonance Imaging (MRI) findings (thought to demonstrate lesions that are not visualized with conventional MRI sequences) and conventional MRI findings correlate with discharge MRS and Glasgow Coma Scale scores in 26 patients with diffuse axonal injury. Using Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients, the results of this study showed that the strongest correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was between signal-intensity abnormality volume on diffusion-weighted images and MRS score, which was excellent (r = 0.77). For lesion number, the strongest correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was between lesion number on images acquired and all sequences and MRS score, which was also excellent (r = 0.66). For lesion location, the strongest correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was between lesion location in the corpus callosum and MRS score, which was adequate (r = 0.51). There was an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the MRS and the Glasgow Coma Scale.

Predictive:
Weimar et al. (2002) identified the most important predictors of adverse outcomes on the Barthel Index (BI) and MRS following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The most relevant predictors were MRS scores before the strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. event, the presence of diabetes, and severity of left arm weakness.
Note: Although MRS scores > 3 was an inclusion criterion in this study, it did not specify how the MRS scores were obtained before the strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. event.

Construct:

Convergent/Discriminant :
Tilley et al. (1996) found that the MRS was closely related to the Glasgow Outcome Scale (94% agreement; Φ = 0.88) and with impairment measured by the NIH StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale (86% agreement; phi coefficient = 0.67) and the Barthel Index (87% agreement; Φ = 0.76). These results raise concern about the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the MRS. The results of this study lends support to the assertion that the MRS is closer to a disability scale than a handicap scale.

de Haan, Horn, Limburg, van Der Meulen, and Bossuyt (1993) evaluated 87 patients who had a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. 6 months prior to evalutation. Impairments were scored on five strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. scales: the Orgogozo Scale, the National Institutes of Health StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale, the Canadian Neurological Scale, the Mathew scale, and the Scandinavian StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale. Disability was assessed with the Barthel Index, handicap with the MRS, and quality of life with the Sickness Impact Profile. The correlations between MRS and the 5 impairment scales using Pearson’s coefficients ranged from adequate to excellent (ranging from r = -0.56 to r = -0.71).
Note: Some correlations are negative because a high score on the MRS indicates increased impairment whereas a low score on other measures indicates increased impairment.

de Haan, Limburg, Bossuyt, van der Meulen, and Aaronson (1995) reported a strong relationship (using Somers’ D) between activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living as measured by the Barthel Index (0.73) and the subscales of the Sickness Impact Profile including Instrumental activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living (0.65), Mobility (0.60) and Living arrangements (0.74) The weakest associations reported were between the MRS and the Sickness Impact Profile subscales of Cognitive Alertness (0.34) and Social Interaction (0.37).

Wolfe et al. (1991) administered the MRS and the Barthel Index (which assesses disability) to 50 patients post-stroke. The correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the MRS and the Barthel Index was measured using kappa statistics. There was an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(kappa = 0.72; weighted kappa = 0.91) between the two scales, which lends support to the assertion that the MRS is closer to a disability scale than a handicap scale.

Responsiveness

Dromerick et al. (2003) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the MRS in comparison to 3 other disability scales (the International StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Trial Measure; the Barthel Index (BI); the Functional Independence Measure (FIM). The MRS was administered to 95 strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation inpatients at admission and at discharge. The MRS was poor at detecting change. When compared to the FIM, the receiver operating characteristics analysis showed that the MRS (C-statistic C = 0.59) was much less sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
to change compared with the BI (C-statistic C = 0.82), indicating a corresponding lower specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
for the MRS. The MRS detected change in 55 subjects, including all who changed on the International StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Trial Measure. The BI detected change in 71 patients and the FIM detected change in 91 patients. The results of this study suggest that the global scales (MRS and the International StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Trial Measure) are much less sensitive to changes in disability than the activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living scales (the BI and the FIM).

References

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See the measure

How to obtain the MRS?

Please click here to obtain a copy of the MRS and the MRS-SI.

The MRS is also available in New, P. W., Buchbinder, R. (2006). Critical appraisal and review of the Rankin Scale and its derivatives. Neuroepidemiology, 26, 4-15.

The MRS-SI can be found in Wilson, L. J. T., Harendran, A., Grant, M., Baird, T., Schultz, U. G. R., Muir, K. W., Bone, I. (2002). Improving the assessment of outcomes in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.: Use of a structured interview to assign grades on the Modified Rankin Scale. Stroke, 33, 2243-2246.

On-line training can be obtained at http://www.rankinscale.org/ The training modules comprise an introductory description of the mRS followed by 4 brief patient interviews. These interviews should be scored anonymously for practice purposes before optional group discussion. Correct scores and their justification follow each case (20 minutes). A transcript of the interviews is available. Certification of successful training will depend on correct completion of 5 further scenarios under ‘test’ conditions. Certification lasts for one year, after which re-certification is recommended. scenarios.

Link to MRS training program: http://www.rankinscale.org/